A pilot project in Uganda which took voluntary counselling and testing into the homes of people already receiving care for HIV has nearly quadrupled the rate of HIV diagnosis and has ended up providing treatment for a large number of untested children who would probably otherwise have died undiagnosed.
The researchers, who describe the home-visit approach as ‘operationally feasible’, urge cost-benefit analysis to see if it can be extended nationally.
The study was an evaluation of the Home-Based AIDS Care (HBAC) project. This randomised patients receiving antiretrovirals via the Ugandan NGO TASO in the districts of Tororo and Busia in SE Uganda either to standard clinical referral or to household voluntary councelling testing (VCT). The study was conducted between May 2003 and December 2004.
Patients randomised to household VCT had all members of their household (defined as all people who shared food and slept in the same house) offered a test for HIV. Those who tested positive received access to clinical care, antiretrovirals if their CD4 cell count was under 250 cells/mm3 or they had AIDS-related symptoms, and, if they were adults, sexual risk reduction counselling. HIV-negative spouses of positive patients also received counselling.
Getting an HIV test was not a requirement in order to receive clinical care, but in fact 99% of all household members accepted an HIV test. Couples were encouraged to test together.
If children were under nine years of age, their guardian consented to a test; if they were between 10 and 17, both the child and the guardian had to consent. This was relevant because children formed the majority of household members; the median age of those tested was 12.
Altogether, 2,348 household members were tested with only 25 refusing a test. Of these, 2,232 had never taken an HIV test. 1,575 of those tested were under 14, of whom only one had ever taken a test before. Three-quarters of adults had never taken an HIV test.
One hundred and seventy-six new HIV infections were diagnosed (7.5% of the whole group). One hundred and thirty of these were new diagnoses, 43 of which were among children under five years old. HIV prevalence among these children was 9.5%; it tailed off to 3.2% amongst 6-10 year-olds and 1.7% among 11-17 year-olds.
HIV prevalence among children under five with HIV-positive mothers was 19.5% but tailed off to similar levels (2.1%) amongst 11-17 year olds, indicating huge mortality from AIDS among young children. As the researchers comment, without treatment 50% of children with HIV die before their third birthday. One child of an HIV-negative mother tested positive.
HIV prevalence was similar between genders except that it was four times higher among women ages 18-24 than men (9% vs 2.2%), and twice as high among men over 35 years than women (22% vs 10%). This was particularly the case among older adults (45+) where among those who had never tested, 2.5% of women were positive compared with 13.5% of men.
One hundred and twenty of all those tested were spouses of the index patients. Of these 89 (74%) had never tested before and 68 (57%) were HIV-positive themselves or, to put it another way, 43% were in an HIV-serodiscordant marriage. Of these 52 HIV-negative partners, only one had previously taken an HIV test.
It terms of eligibility for antiretroviral therapy (ART), 39% of all those testing HIV positive had CD4 counts under 250 or AIDS-related symptoms; this rose to 42% of children under five. There was again a big gender difference with nearly half (47%) of men and boys eligible for ART compared with a third (34%) of women and girls.
Of the 773 people over 15 years of age who had never tested before, 52% said they had not tested because they did not perceive themselves to be at risk, 8% because it was too far to the clinic, and 17% because they feared knowing their status.
The researchers claim that only 1% said they had not tested because of lack of availability of ART. Although this might be hidden as a reason for not testing because it could be just one factor in fearing knowing one’s status, the researchers quote previous research of household VCT in which ART was not on offer but 97% still accepted voluntary counselling and testing.
In terms of the impact of diagnosis, the researchers say that follow-up visits three months after diagnosis found “substantial increase among positive social events, such as strengthened relationships and community support, and no increase in negative events” compared with three months before enrolment.
Given that HIV prevalence among 15 to 44 year-olds who shared a house with someone already diagnosed was three times the estimated national average, home-visit VCT could be cost-effective, and the researchers say it is ‘operationally effective’ as it could be done by TASO volunteers using fingerstick rapid testing, an approach supported by the Ugandan health ministry.
Were WA et al. Undiagnosed HIV infection and couple HIV discordance among household members of HIV-infected people receiving antiretroviral therapy in Uganda. JAIDS 43(1), 91-95, 2006.